Shhh ... members of Great Ormond Street Hospital perform during the opening ceremony of the London 2012 Olympic Games. Photograph: Alex Livesey/Getty Images

Next month the NHS in England undergoes one of the biggest restructurings since it was first created. Responsibility for the service is being moved from the Department of Health to a new "NHS commissioning board"; budgets are, in theory at least, to be put more into the hands of GPs; and the NHS will focus on improving "outcomes" rather than meeting government "targets". The changes come just weeks after the results of a public inquiry damned the "culture of the NHS" for failing to protect patients from appalling standards of care.

It is 6 February and the camera crews have gathered outside the Queen Elizabeth II conference centre in Westminster, a squat, misshapen 1970s block that sits like a vast concrete bullfrog staring balefully at the beauties of Westminster Abbey opposite. On the paved area in front of the centre, satellite vans have parked and technicians are setting up microphones and lights. It is a cold day with a sharp wind from the north. The journalists lift up the collars of their coats as they prepare to broadcast. They are here for the verdict of the Mid Staffordshire NHS Foundation Trust inquiry; or, perhaps more accurately, the verdict to be pronounced on the NHS. It is now four years since evidence of appalling standards of care at an NHS hospital in the West Midlands first came to light. In the intervening years, the name of Mid Staffordshire has been hung around the neck of the NHS as a badge of shame. Any claim the organisation might have made to be a force for good in the country has been undermined.

A succession of investigations have taken place and the facts have become clear. For more than four years, from 2005 to 2009, standards of care in parts of the hospital collapsed. In the emergency department at Stafford Hospital and, most notably, in wards 10 and 11, the lives of patients were turned into a living hell. They were denied vital medical treatments, they were ignored, they were humiliated and left in pain and discomfort. Many spent days and nights on these wards in fear for their safety and scared to complain. For a significant number, this was their last experience before they died unnecessarily through lack of decent medical care.

That much is clear. But one question remains to be answered: who is to blame? Because this is about more than the events that took place in the hospital. This is about the fact that, at various times, there were people at every level of the NHS who had been in a position to spot the problems. There were many who had both the responsibility and the opportunity to intervene. And yet nothing had been done. No one had acted. Guilt by association tainted every part of the NHS.

A lawyer, Robert Francis, was appointed to find out what happened. He was asked, in particular, to uncover "why problems at the trust were not identified sooner". In other words: who was responsible, who should have done something? The list of suspects was long. The nurses and doctors treating the patients, the board of the hospital, the GPs who referred their patients, the local NHS commissioning organisations, the regional health authorities, the managers in the Department of Health, the regulators and, ultimately, the politicians in Westminster. All of them had some connection to the scene of the crime. But who was guilty?

As the time of the announcement approached, the crowd gathered. People arrived who had suffered at the hospital, along with families of people who died there. Many of them had campaigned for years to demand some form of justice. Julie Bailey, whose mother died in Stafford Hospital and who founded the campaign to "Cure the NHS", was there along with many who had given evidence to Francis.

People from the NHS also arrived, heads down, waiting to hear the worst. When the verdict came, there was not so much a gasp as a frown. When all the evidence had been sifted; after the lawyers had carefully judged the behaviour of the politicians, the bureaucrats, the doctors and the nurses; after their claims and counter-claims were weighed and the legal issues considered – it turned out none of them were to blame. It turned out that, all along, lurking in the background like the butler, it was the "culture" that had committed the crime.

The victims and their families were not happy. The culture of the NHS is not something that can apologise and try to atone. The culture of the NHS cannot be punished for its misdeeds. They wanted to see someone held to account. They wanted to know that they were not the only ones to suffer through this disaster. More than anything, they wanted to see the chief executive of the NHS forced out of his job.

But the verdict was clear. It was, Francis announced, not possible to castigate "failings on the part of one or even a group of individuals". There was no point in looking for "scapegoats". The guilty party was the "culture of the NHS". It was the culture that had ignored "the priority that should have been given to the protection of patients". It was the culture that "too often did not consider properly the impact on patients of actions being taken".

The restructuring of the NHS is designed to change its culture and make it more sensitive to the needs of patients. But the culture of the NHS goes far beyond its many, often conflicting, institutions. The starting point in understanding it is the unique political context in which our health services operate and the way in which we, the public, think about our NHS.

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We love our health service. We love it in a way that has no parallel in other countries. Few people in Britain call into question the healthcare system. In one 2012 study, only 3% of people felt the system needed to be overhauled. The next most satisfied country has more than twice as many people questioning their arrangements. It compares with a rate of about 10% across Europe and 25% in the US. The social consensus is so strong around the NHS that dissenting voices sound jarring. When a Conservative member of the European Parliament, Daniel Hannan, described the NHS as a "mistake" on US TV, there was genuine shock and surprise back home. David Cameron described his opinion as "eccentric". He was right. People in Britain do not hold views like that.

It is not unusual to hear people protest that they "will not hear a word said against" the NHS. Criticism can quickly become blasphemy. And the praise at times becomes daft. Take this example from the Times, in which Caitlin Moran, in a review of a TV programme about the NHS, wrote: "Oh, the fabulous luxury of the NHS: the only profligacy that isn't profligacy at all – but some rare blend of care, civilisation and sanity that still feels like one of the great wonders of the world. For all the good it has done, has humanity ever topped its brilliance – even in the Great Pyramid or Rhapsody in Blue?" She goes on to say how, in other countries, people would wake in their hospital beds and be presented with the bill. But here, with the NHS, you wake surrounded by relieved and grateful loved ones. She sums up how many people in Britain feel. We believe that the NHS is a remarkable and unusual arrangement. We believe that it is different and ahead of what goes on in other countries. Many people believe that the very idea of universal healthcare – making sure everyone can access care when they need it regardless of wealth – is an idea invented in Britain and uniquely realised in Britain. None of this is true. But it leads us to hold the institution of the NHS in a peculiar reverence.

When Moran gushes that the NHS is one of humanity's great achievements, she is mixing up a lot of things. Much of her admiration comes from her astonishment at the ability of doctors to save people's lives. She is right to be astonished – this does indeed rank among the greatest achievements of humanity. But modern medicine and the NHS are not the same thing.

Modern medicine deserves hyperbolic descriptions. Highly skilled people working in high-pressure environments using some of the most remarkable technology ever developed to overcome what, at times, seem insurmountable odds to restore people to health is awe-inspiring. But the NHS is not a particularly awe-inspiring example of modern medical care. It has some shining examples of world-class treatment, but it also has some distinctly less impressive examples of poor practice.

Our relationship with the NHS is better explained by the way it came into existence. Because the NHS was created as a single national entity, we have a single national brand that encompasses almost every aspect of the healthcare we receive. The letters NHS represent the whole package: they stand for social equality and universal healthcare; they stand for the doctors and the nurses who treat us or our relatives and to whom we are grateful; they stand for the miracles performed daily by modern medicine; they stand for the financial systems that make sure we don't have to worry about paying.

It is hard for people in other countries to feel such a strong attachment to their national healthcare system because there is often no obvious brand to which sentiments can attach. It is hard to imagine how people could feel a similar sense of loyalty to their health insurance policy or the particular hospital in their town.

When it comes to the people who care for us, there is a basic human need to give them our trust and respect. When we are saved from danger, regardless of whether this has been done well or poorly, it is impossible not to feel a deep sense of gratitude. The UK is unusual in that, to a large degree, the emotions that attach to the people and the particular institutions that look after us also attach to our national system of healthcare delivery.

This can result in confusion. When people criticise the NHS, it can seem as if they are denigrating the heroic individual who saved your mother's life or the value of modern medicine. This can undermine our ability to talk sensibly about health.

At times, praise of the NHS replaces patriotism as the last resort of scoundrels. British politicians no longer wrap themselves in the flag, they wrap themselves in the blue and white of the NHS logo. When a politician says he loves the NHS, it is time to start asking some difficult questions. When Cameron says he loves the NHS, what exactly is he referring to? Is it the nurses and doctors he has come into contact with? Or does he mean the institutions and organisations within which so many NHS employees work? Presumably not the latter, since his government has abolished so many of them.

The political culture within which the NHS operates – and the fear of political repercussions if services are found wanting – has resulted in a tendency to reassure patients and the public that services are safe and care is good even when such claims are open to doubt. We can hardly be surprised if there is then confusion as to what really does constitute safe care.

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The public inquiry into Mid Staffordshire hospital NHS Foundation Trust took place in the offices of Stafford borough council – a red-brick, low-rise office block at the end of the main street with a branch of the Royal Bank of Scotland and a shop selling discount white goods on the ground floor. Public inquiries are courts of law, but they usually take place in municipal buildings requisitioned for the purpose. The inquiry had been given space on the fourth floor of the office building. A large function room with neutral fittings and strip lighting was arranged with rows of desks facing the back of the room where Francis, leading the inquiry, sat on a raised stage. His desk faced the rows of lawyers, reporters and interested members of the public. Unlike in a normal court, there was no dock. No one was on trial. Or rather, everyone was. Everyone was there to account for themselves before a judge.

To his right, a desk was arranged facing across the room at an angle. This was the witness stand. A cast list of more than 150 people – from ministers of state, the chief executive of the NHS, through all the ranks of regulators and managers, the doctors and the patients – sat there and gave their version of events. Everyone was sorry for what had happened. And everyone was able to put forward a good reason why they could not be held responsible. The reasons are familiar. "I didn't know" remains the favourite.

Many commentators on the problems of Mid Staffordshire have been baffled by an apparent contradiction. Here is a failure that everyone agrees is exceptional, that affected hundreds of patients, that went on for years. And yet it is a failure that was not readily apparent to anyone involved at the time. Why did so few people – in particular the doctors and nurses – object to what was happening? Reading through some of the stories of patients, it seems inconceivable that staff did not down tools in protest.

The apparent contradiction is, in part, the result of the desire to put Mid Staffordshire into a separate box and label it "bad" while all around is "good". It is understandable. But it is very unfair on many of the people involved. One reason why the failures at Mid Staffordshire did not prompt in staff the horrified reactions of those who read the reports of the inquiry was that, in truth, it was not quite as exceptional as it has since been made out to be.

Paul Woodmansey was a senior doctor at Stafford throughout the period when things went wrong. He is mentioned by a number of patients for whom his department provided a haven of professional, high-quality care while standards in other wards collapsed. He wrote to the Royal College of Physicians journal saying: "Many colleagues elsewhere have expressed relief that it was our hospital not theirs which had received such in-depth scrutiny. It is difficult for anyone to maintain objectivity in the face of such a media storm, and I suspect that similar instances of poor patient care could have, and perhaps can still, be found elsewhere." In other words, Mid Staffordshire was not a unique case. If anything, it was at the extreme end of a spectrum that shades gradually from excellent, to tolerable, to awful. Questions of scale are harder to judge than questions of substance. We know that there was often chaos in the A&E and emergency admission unit at the hospital. But then many A&E departments have moments of chaos, many of them have safety issues. How do you know what level of chaos is no longer acceptable?

One piece of jargon from the world of patient safety illustrates the point. "Never event" is a term used to refer to things that should never happen. The term was devised to focus safety efforts on those things that no one would try to defend – things like operating on the wrong part of the patient. NHS hospitals have a duty to record and report how often "never events" take place. As this rather Orwellian instruction implies, it is rather more frequent than "never". In the first year of the scheme, 111 such events were reported across the NHS.

Efforts to focus attention on these events have been effective at reducing their number. However, the fact remains that they continue to occur, with sufficient regularity that they do not on their own signal that a service has become unacceptably poor. Although everyone agrees that these events are wholly unacceptable, those same people would not agree that the occurrence of a never event implies that a service is unsafe. For that, there would have to be too many "never events". But how many is too many? How do you spot when the level of unacceptability has become unacceptable?

It is the same problem with avoidable deaths. The occurrence of an avoidable death might seem like a clear signal that a hospital service is unsafe. It does not. Or at least not officially. Walsall Hospital currently has a big tick from the Care Quality Commission for treating patients safely. In 2012, it reported 2,693 safety incidents to the National Reporting and Learning Services over a six-month period, of which 80 resulted in severe harm and 14 resulted in death. These figures are not unusually high.

Preventing these events from happening is incredibly hard, and no hospital has managed to eradicate them. The point is simply that when you realise that 80 cases of severe harm and 14 deaths is "safe", it is easier to understand how it might not be immediately obvious to frontline staff when the line from safe to unsafe has been crossed. Because there is no line.

This is the problem – or rather one of the many problems – that confronts anyone thinking of becoming a whistle-blower in the NHS. If you step forward and say things aren't good enough, what is your evidence? By whose standard of safety are you making that judgment?

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The problems the NHS faces are, in the main, no different from the challenges that confront the health services of most developed economies across the world: the provision of reliable, high-quality healthcare in the face of rising demand and limited budgets. But the reform agenda put forward by Cameron's government has failed to find support among the public.

Of all the changes enacted by the 2012 Health and Social Care Act, the decision to abolish a large number of the organisations that comprise the NHS and replace them with a whole new set of organisations that only those with the most arcane interest in NHS management structures will ever be able to tell apart is probably the least useful. It has cost the NHS somewhere between £1bn–£2bn in direct costs and countless more in terms of the knock-on consequences.

There is little point in going into the pros and cons of these different NHS organisational structures – it is tedious beyond belief and, in the end, all such reorganisations have failed spectacularly to cause anything to change, aside from letterheads and job titles.

It is more interesting to look at some of the changes that affect the people who deliver care to you and me. Let's take three issues that illustrate the problem and that have concerned Labour governments as much as they have concerned Conservatives.

First, there is the role of doctors in the management of health services. The reformers believe that getting doctors to decide how NHS budgets are spent is essential. Yet much of the public thinks it makes about as much sense as asking NHS accountants to perform major surgery.

Second, there is the constant drive to close down hospital services and transfer them either into the community or else into more specialised centres of excellence. This is by far the most unpopular thing a government can do, and yet there is no prospect of the trend halting.

Finally, there is the desire to get more private sector organisations involved in delivering services. Most of the public opposes it. Most health ministers, both Labour and Tory, in recent decades have promoted it.

These are all areas in which the policies being enacted have been widely endorsed by those who work in the area of NHS policy. But they have failed to gain full acceptance even among NHS staff, let alone among the wider public. You do not hear people in the pub complaining that no one has shut down the dreadful local cancer clinic because of its poor outcomes; or bemoaning the shocking lack of engagement by the medical profession in fixing the financial problems facing the NHS. You might occasionally find someone in the corner complaining that the NHS should be handed over to the private sector. But you will probably want to steer well clear of him as he slumps against the bar after six large gins. In any event, his voice will be drowned out by the cries from the other end of the bar that all the NHS needs is more money.

The policies that address the economics of healthcare have not won over the British people. This is the tension that underlies the political debate. Those opposed to reform face enormous economic obstacles. Those in favour of reform face an indifferent or often hostile response from large sections of the medical profession and the public.

The result is a sort of policy "groundhog day" in which governments enact reforms that fail to get traction and so fail to produce the hoped-for improvements. They respond to this with another set of reforms that appears to the untrained eye to be little more than a rehashing of the previous set.

At the heart of the problem is Mid Staffordshire, and this is because it reveals the weakness that undermines all the current proposals. If we are to ask doctors where money should be spent to produce the maximum benefit for patients, they will have to know which activities are making patients better and which are not. If the public is to be told that closing a local A&E will result in a better service, someone will have to properly work out whether or not those services do, in fact, improve. If we are to invite profit-making organisations to deliver healthcare, we must have a way of ensuring that they have not simply pocketed the cash and fobbed us off with the cheapest substitute for a health service they could lay their hands on.

It is simple really. If the NHS is to be reshaped in ways that are deeply unpopular, those within the health service must be able to tell the difference between good care and bad. The verdict from Mid Staffordshire is that they cannot.